Beruflich Dokumente
Kultur Dokumente
Foreword 2
A good start 4
Core principles 16
Getting started 18
Involving staff 21
Conclusion 23
Acknowledgements
We asked the Lean Enterprise Academy to look at
how Toyota’s approach to production could be
applied to healthcare. This is not as odd as it first
appears. The Toyota system – often known as Lean –
has been applied in many environments, including
healthcare (and not just manufacturing) for some
time now, with staggering improvements in quality
and efficiency. The underpinning values of removing
activities that don’t add value and of respect for
people and society lie at the heart of healthcare.
And the principles on which Lean is based are
generic. They can be applied anywhere: at home,
in a bank,
Although the NHS has made significant progress
over the last few years, there is a nagging doubt that
the improvements should have been more significant.
Also, there are many significant challenges that still
need to be addressed, including:
• financial deficits
• hospital acquired infections and avoidable injury
and death
• capacity constraints
• accusations of endemic inefficiency
• public and political concern about waiting lists
and costs.
But problems like these are common to many
industries. Poor safety and quality, capacity
4 Lean thinking for the NHS
A good start
Like many NHS services, the pathology department journey from one location to another (otherwise
at the Bolton Hospital has grown like topsy. every day would be a marathon). Samples were
It currently employs over 100 staff across many analysed on a batch and queue basis, with one day’s
specialisms. Their daily work conducting thousands samples gathered together for analysing the next
of tests each day, using a wide range of specialist day. This meant a minimum 24-hour turnaround
equipment, is vital to the effective functioning of the standard for some tests.
hospital and the NHS trust as a whole. But both its
users and its staff experience daily frustrations. Tests Having seen how the system actually worked, the
take longer than they should, causing delays. Staff staff saw many ways to improve it. Why not:
feel they are under constant pressure.
• knock rooms together so that staff can go directly
from A to B instead of having to travel via the
corridor?
Mapping the work
• place analysers together so that staff don’t have
Recently, however, a team of staff at the hospital to trek up and down stairs to access them?
took a step back to see how their department really
• move the central sample receiving point to the
worked. They followed blood samples on their
middle of the department, to minimise the
journey from the patient, through the haematology,
sample’s journey from receipt to analysis?
biochemistry and microbiology laboratories and
back again, and painstakingly tracked every step • create a standard sample request form for blood
the sample took – received with a request form, sciences that can be scanned into the computer,
checked to make sure the sample is from the right thereby eliminating a large amount of time-
patient, assigned a unique laboratory number for wasting, non value-adding clerical work?
processing through the IT system, information input
• analyse each rack as soon as it is filled rather than
into the computer, and so on.
accumulate a whole batch of samples?
When they looked at the department’s processes
Such detailed suggestion may not sound like much.
like this, end to end, a number of blockages and
But put together in the right way, the results were
unnecessary steps became immediately obvious.
dramatic. A routine blood sample’s journey once
For example, they could not analyse a sample before
involved 309 steps, but with a redesign of work,
the information had been put into the computer
machine relocation and so on, this could be reduced
but inputting delays are common, caused by
to just 57 steps. Urgent blood sample steps could be
samples arriving in large batches. And once they
reduced from 75 to 57, and so on. Simply relocating
had the information, taking the sample to the
two analysers from the first floor to the ground floor
analyser could be quite a trek.
and redesigning the work space would reduce the
distance staff have to walk each day by 80 per cent
Over the years, as the department grew, new space
– saving huge amounts both time and energy. All in
was found in two buildings separated by the main
all, the time taken to process samples for endocrinology
hospital corridor, upstairs and downstairs, in
and haematinics could be cut from between 24 and
a number of separate rooms. And as new machines
30 hours to between two and three hours.
were purchased, they were placed wherever room
could be found: some on the ground floor on one
side of the corridor, others on the first floor on the
other side. Staff stored work before making the
What’s more, the same amount of work could be
done with fewer staff (who are being redeployed to
more productive activities), and the actual amount
of space used by the department could be reduced
by 50 per cent. This had further knock-on benefits
for the blood transfusion department. Before,
the department was located at the end of a long
corridor which staff had to walk up and down in
order to collect or deliver blood products. Now it
could be moved closer to the wards, saving even
more time and energy.
6 Lean thinking for the NHS
“We hadn’t been sitting on our hands. We had tried • improved quality and safety: fewer mistakes,
everything that was common practice for dealing accidents and errors, resulting in better patient care
with this kind of problem. But nothing had a big • improved delivery – better work gets done sooner
enough effect to really help us out.”
• improved throughput – the same people, using
Before, “we simply did not have any sense of being the same equipment, find they are capable of
in control”, says David Ben-Tovim. “Now the institution achieving much more
as a whole is much more optimistic. This year, it is • accelerating momentum – a stable working
coming in below its budgeted costs. So, for the first environment with clear, standardised procedures
time in years, it is able to invest some of this surplus creates the foundations for constant improvement.
in much needed equipment. At the same time,
gross errors are being squeezed out of the system. There is another benefit that comes with each wave.
For example, the number of notifications [where Staff morale improves. “What makes Lean so
the hospital is sued for errors that cause death or powerful,” says David Fillingham, chief executive of
disability] has fallen dramatically from 87 when the Bolton NHS Trust, “is that it engages the
we started to 32 last year. And many of these enthusiasm of front-line staff.”
notifications are coming from areas of the hospital
we haven’t reached with Lean yet.” Flinders and Bolton are still at the beginning of their
journeys. But both are now convinced Lean can save
healthcare. But why? And how?
Why does Lean work? The answer is simple. Lean
tackles the heart of the matter: how the organisation’s
work gets done.
Disconnects are also compounded by cultures pharmacy to label products better. So the cause of
of expertise where specialists create islands of the problem never gets addressed.
excellence at what they actually do, but everything
else is invisible to them. In fact, in the NHS today,
nobody ever sees the end-to-end patient journey Things get compounded
from admission through to discharge (except for
patients themselves) it is no one’s job to manage A basic lack of visibility, confused responsibilities,
this journey as a whole. So disconnects are almost unnecessary work, disconnects, extra work-arounds:
built in to how the system operates. they all add up and tangle with one another. And
the more complex things become, the greater the
Inappropriate measures and targets chance of errors that undermines quality and/or
threaten safety. For example, if there is a 5 per cent
Many accounting measures such as unit cost and chance of making a mistake for each step in a series
asset utilisation focus on just one isolated part of a of tasks, and if there are 50 steps, the chance of getting
complex process. Subsequent attempts to improve them all right is less than 1 per cent (see Figure 2).
efficiency and productivity simply pass costs on to Many NHS processes involve hundreds of steps, so
another department rather than improving the what chance is there for an error-free outcome?
efficiency of the process as a whole. For example, a
buyer buys bulk supplies to qualify for a volume
discount, which reduces unit costs. But because the Frustration dissipates energy
supplies are not needed immediately, cash is tied up
in inventory and extra time and money has to be Because the quality of the organisation’s core
spent storing the excess stock, accessing it etc. processes is poor, mistakes are made and the
organisation gets sucked into endless fire-fighting.
A blaming culture can take root. More and more
Problems are not resolved of the organisation’s resources are dissipated
working around, rather than resolving, its underlying
When things go wrong, it creates extra pressure to problems. Staff want to do a good job, but the
‘get the job done’, whereas, invariably, getting to the system doesn’t let them.
root of the problem takes extra time and effort and
usually requires the co-operation of some other
party. The nurse cannot tell drug companies or the
The Lean opportunity The time spent actually treating the patient was 100
minutes. The total time actually required to deliver
Lean brings two things to the party. First, it turns a this treatment was 610 minutes on the part of the
big problem into a huge opportunity. From a Lean patient, and 330 minutes on the part of the hospital.
perspective about 95 per cent of everything most But the whole process took 31 weeks, most of which
organisations do is not value adding. Some of these
activities are very hard to eliminate. (Paying invoices
doesn’t directly improve patient care, for example,
but it has to be done.) On the other hand, many
of these non-value adding activities are avoidable.
Another way to clog the motorway would be Any contact needed between members of staff to
to construct it in different sections with poor achieve a task is known as a hand-off and is a source
connections between them. The NHS is full of such of potential delay or error. When Bolton Hospital
disconnects. We’ve seen some examples already. mapped the hand-offs needed to complete a
A test fails to arrive before a consultant does his complex discharge, it discovered more than 250 (see
round, so treatment gets delayed. Liaison with Figure 4). The more hand-offs there are, the greater
social services and transport services breaks down, the chance of something going wrong. Then traffic
so the patient isn’t discharged as planned. comes to a halt when it should be flowing.
Discharge co-ordinator
Patient
Consultant GP
Outpatient Doctor Ambulance
echocardiography Ward clerk
Pharmacy technician X-ray
Audiology Pharmacy
Core principles
We are now in a position to summarise the Lean the finish – as a single integrated whole. Each step
approach to performance improvement. in the process needs to be designed with an eye to
the effects it has on the steps that precede it and
follow it – so that they all link together seamlessly.
Patient perspective
Under Lean, value is defined solely from the customer’s What Lean is not
perspective – in our case, this will generally be the
patient. Anything that helps treat the patient is value Lean is not restructuring
adding. Everything else is waste. Lean eliminates waste
and reinvests released resources in value creation. Lean is about changing the work itself, not
about who gives what orders or who reports
to who. All too often, organisational
Pull restructuring and reorganisation is merely
a displacement activity. If the actual work
To create value we need to provide services in line people do does not change and improve, then
with demand. No less. And no more. Delivering care restructuring is irrelevant. And if restructuring
in line with demand means not producing it to interferes in the way work should be done
meet some other, artificially imposed metric such (as it often does) it is worse than useless.
as a productivity, asset utilisation or unit cost target. Sometimes, organisations need restructuring.
(Performance is a by-product of how the system But the general rule of thumb is that
works and not an end in itself. If we eliminate waste, restructuring should happen after the basic
budgets and targets will be met along the way). work problems have been sorted out, not before.
Pull leads to flow where each patient is worked with, Ward pull in practice
one unit at a time, and passed on for the next step
of the process without any delay. A preoccupation Moving to flow and enabling pull is often counter-
of Lean is to identify blockages and obstacles that intuitive to traditionally trained managers, who
cause delay, and to remove them. tend to think in terms of push, for example when
a patient is ready for admission in accident and
Value streams emergency they are found a bed. Like many
hospitals, Flinders Hospital in Adelaide used to
For flow to happen we need to design and manage organise bed allocations in this way, with beds
each value stream – each sequence of steps that adds allocated to patients according to an assessment of
value for the patient from the start of the journey to clinical priority – urgent cases were put in any bed
that became vacant. To manage these bed turnover has increased 20 per cent, with the median
allocations, the hospital developed a complex length of stay reduced by one day. At the same
central bed management role. Bed managers were
responsible for pushing patients into wards, even if
the ward did not specialise in that illness or injury.
This not only generated conflict and irritation, it
also created inefficiencies and safety concerns.
For example, clinical teams had to spend increasing
amounts of time and effort travelling to and from as
many as ten different wards – just to see their patients.
Getting started
So, how can hospitals start the journey towards conditions. The difference with Lean is that we focus
Lean? Most Lean initiatives involve three basic steps: not on similar clinical conditions but similar processes.
• identify value streams
As David Ben-Tovim at Flinders puts it: “In a hospital
• map value streams a value stream is the end-to-end process of caring
for a group of patients (a patient-care family) whose
• identify and implement immediate, medium-term
overall care processes have enough in common for
and long-term improvements.
them to be managed together, irrespective of clinical
Let’s touch on each of these in turn. diagnosis or existing professional boundaries: short
things, long things, simple things, complicated things.”
Home
A&E
Elective Outpatient
Home
(e.g. outpatient, day surgery)
and to redesign these systems to enable flow – each
patient moving on to the next stage seamlessly,
without any unnecessary work or waiting. No traffic
lights. No disconnects. No ambiguity or confusion.
pamh k s a t ro
–Pbtd
–p–"!"@ ''0–A
‡ †wR
†rx2
b
Ø–†P‡–O
–2Wî
†r@–ò rrb
} –QàV$‡@Ζ''0–
`–† ‡ 0 ¨ Í â ‡ Qàx–@ Eì¿ ocurasts
‡ @ ¿ " paí
Ä an
¿Í –ô idtal
–I@ q$ ¿ )êyëb† –turg
† –Ä –¿ ¿ rr ‡ stst
‡ 2† ’
Lean thinking for the NHS 21
Involving staff
To succeed Lean needs to clear a crucial hurdle. An “You need to create a shared, joint view of what is
almost inevitable result of Lean initiatives is that less going on,” says David Ben-Tovim at Flinders. “This is
people are needed to achieve the same (or more) very important because, for example, in hospitals
results. So, potentially, people could lose their doctors find it hard to listen to anyone else. If they
jobs. What’s more, the changes made in Lean want to, doctors can stop things from happening.
improvement projects can happen unsettlingly And we need them on board.”
quickly: once a Rapid Improvement Event is under
way, working practices that have been ‘the way we A third lesson is that people’s pride and dignity need
do things around here’ for years can be swept away to be protected when collecting information about
within a week. So feathers will get ruffled. what actually happens – because invariably
it will throw up practices which, when seen in the
Yet, for Lean to work, it needs the active, enthusiastic cold light of day, look stupid. That makes the
cooperation of staff: it will never happen by order underlying Lean message all the more important:
of the management. Indeed, because Lean is about any problems that are uncovered are not the fault
changing the way people work, the most important of the individual but the system.
people in any Lean exercise are not managers,
consultants or any other form of expert, but the Says Ben-Tovim: “We work hard to make sure that
people who know this work inside out: staff themselves. everybody’s voice is heard, that there is no hierarchy,
that there is no culture of blame, and that people go
So how can this circle of apparent threats to job away feeling listened to. It has to be about respect.
security and the need for staff involvement be Our basic assumption is that people want to do a
squared? The lesson from long experience is that good job and that we have been making it impossible
Lean initiatives rarely succeed unless continuity of for them to do a good job. We use humour, for
staff employment is guaranteed in advance. That is example, because it is very important to make people
why implementation of Lean has to be separated feel OK about having their deficiencies exposed.”
explicitly from short-term, end-of-year budget
balancing crisis measures. Lean may be a way of The upside is this: once these foundations – jobs not
avoiding crises like these in the future. But it is not a threatened, involvement at all levels, respect for
magic wand to wave once the organisation is facing people – are in place, Lean initiatives can unleash
one. (Although it was the impetus that set Flinders waves of enthusiasm. “When we started out some
on its journey.) people were very sceptical,” says Bolton CEO David
Fillingham. “But I’ve never seen anything that
A second lesson is that all levels of staff must be energises staff in this way.”
involved, from porter to consultant surgeon, from
ward assistant to top-ranking administrator. While Three secrets of successful
every individual staff member knows more about his implementation
or her particular job than anyone else, most people’s
in-depth understanding stops there. No matter how
clever, expert or professional they are, they do not 1 No redundancies as a result of Lean exercises.
know or understand the work other people do and
will not see how the parts fit together to make the 2 Involve staff from all levels. They are the
whole. By involving staff at every level, across every experts. They will make it happen.
function and department, Lean exercises help
everybody see how the complete ‘value stream’ 3 Show and practice respect for people.
works from end to end, and where the waste is.
22 Lean thinking for the NHS
We started out in this report talking about Lean is the way forward for health for four reasons,
improvements now being made in one small part of argues David Fillingham:
one hospital: the pathology department at Bolton.
• It provides an overall philosophy and a way of
A 70 per cent reduction in the number of steps
setting priorities.
needed to complete most tasks; a 40 per cent
reduction in the floor space needed; up to 90 per • It has a body of evidence-based tools and
cent reductions in the times taken to do its job – all techniques.
achieved with less, not more, staff and with limited
• There is a vibrant Lean community willing to share
capital investment (mostly building works to knock
experience and expertise.
a few walls down). Just imagine if similar results
were achieved across the whole NHS! • It focuses on safety and quality from the patient’s
perspective but enables these to be delivered at
As we saw with the Bolton pathology example this lower cost.
is impossible unless every step of the patient
journey is tackled in a similar way. In fact, there are The potential for continuous improvement is
at least three levels of Lean implementation: therefore genuinely huge: so far, we have barely
scratched the surface.
1 All the points in the patient journeys can be
redesigned to make sure they connect, to
improve the process as a whole from end to end:
admission through diagnosis and treatment to
discharge. This requires that every step of patient
care, and every support process, goes through
the process of value stream mapping and redesign.
Lean practitioners call this ‘system kaizen’.
Although the NHS has made significant progress in the authors describe how Lean can also be applied to health
past few years, some have expressed concerns that even care. They describe how Lean can be used to build on much
greater changes have not been achieved. Certainly the of the work already undertaken in the NHS to improve
NHS still faces major challenges, and increasing public the patient’s journey. Far from being a management fad,
and political pressure to deliver. However, some of the Lean is described here as a tried and tested approach, as
problems the NHS faces – financial problems, safety applicable to healthcare as commerce. It takes time to
concerns and skill shortages, for example, are common embed; while it will not provide a quick fix for all the
to many industries. NHS’ ills, it promises to deliver significant improvements
over the medium- to long-term.
The concept of Lean was developed for Toyota and has
since been used extensively in manufacturing, project Lean thinking for the NHS will be required reading for
management, and product and service development. NHS boards and all those working with them to ensure
In this NHS Confederation Leading Edge report the the NHS is effectively run.
The NHS Confederation’s Leading edge publications are designed to stimulate debate
Lean thinking for the NHS is the second in a series of Leading edge reports commissioned by
the NHS Confederation, offering leading thinkers the opportunity to propose new solutions
to major issues facing the NHS.